ICU Management of CVA, ICH, SAH

AHEC “Time is Brain” 2014
Kirk’s Notes

Hemicraniectomy
1. Malignant MCA hemicraniectomy - consider having a checklist for those who might benefit based on the studies
2. Studies are positive for early surgery, however, “improvement” was bed bound or better outcome. Thus, this is more life-saving than great functional status saves
3. Await 24hrs after TPA. Outcome same if patient did or did not receive TPA initially.
4. Worse outcomes if patient is chronically on ASA. Consider holding post TPA ASA if surgery is being considered
5. 77% of caregivers would do it again for their loved one
6. 41% functional / 47% not functional 

Cerebellar infarct surgery
1. Typically decline 3-4 days later
2. Keep in ICU longer than you would normally for frequent neuro checks
3. Awake/drowsy patients do much better rushed to OR than patients with stupor

ICH
1. 1/3 will expand within 3hrs
2. lower BP probably decreases expansions and studies have shown it is safe
3. ICH without edema goal SBP 160.  ICH with edema SBP 180.
4. Severe ICH on coumadin - consider PCC over FFP. corrects in 1hr but more expensive
5. rivaroxaban (Xarelto) reverses with PCC but dabigatran (Pradaxa) PCC doesn’t help
6. surgery for posterior fossa ICH should be early as preoperative status predicted outcomes
7. surgery for supratentorial ICH - no improvement in outcomes
8. when to restart anticoagulation after ICH, SAD, SDH - 10-30 weeks afib. 7 days PE/valve
9. seizures common. no role in prophylaxis but consider early EEG for subclinicals
10. start DVT prop with hep/lovenox 3-4 days. 15% DVT if untreated.

SAH
1. Consider amicar if transporting to another facility or delay in secure. Max 72hr
2. DCI occurs day 4-14 with peak around 7-9
3. Euvolemia but avoid diuresis if possible until after day 14
4. Increasing MAP is goal for DCI treatment.
5. Poor exam patients consider angio or CT perfusion to look for dci/vasospasm